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Guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association The Essentials 5 th Annual CE LHIN CME Canadian.

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Presentation on theme: "Guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association The Essentials 5 th Annual CE LHIN CME Canadian."— Presentation transcript:

1 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association The Essentials 5 th Annual CE LHIN CME Canadian Diabetes Association 2013 Clinical Practice Guidelines

2 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Dr. John Sigalas Endocrinologist Rouge Valley Health System Toronto May 15, 2013

3 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Learning Objectives By the end of this session, participants will be able to: 1.Understand the major changes within the 2013 CDA clinical practice guidelines 2.Understand the rationale behind these changes 3.Apply the recommendations in clinical practice

4 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Faculty for slide deck development Jonathan Dawrant, BSc, MSc, MD, FRCPC Zoe Lysy, MDCM, FRCPC Geetha Mukerji, MD, FACP, FRCPC Dina Reiss, MD, FACP, FRCPC Steven Sovran, BSc, MD, MA, FRCPC Alice Y.Y. Cheng, MD, FRCPC Peter J. Lin, MD, CCFP Catherine Yu, MD, FRCPC, MHSc

5 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association TIA 2005 Stroke 2006 MI 2003 MI 2004 Bypass 2001 PAD 2002 Ischemic Toes Amputation 2004 Neuropathy 2003 CKD 2002 Retinopathy 2004 ACS 2001 Victor 59 years old Type 2 Diabetes

6 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Victor 59 years old Type 2 Diabetes Neuropathy 2002 TIA 2005 Stroke 2006 PAD 2002 Ischemic Toes Amputation 2004 MI 2003 MI 2004 Bypass 2001 ACS 2001 Macrovascular Neuropathy 2003 CKD 2002 Retinopathy 2004 Microvascular Reorganize his history He has EVERY complication of Diabetes That is what we need to avoid

7 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

8 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

9 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association What is new in making the diagnosis of diabetes?

10 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association FPG 7.0 mmol/L Fasting = no caloric intake for at least 8 hours or A1C 6.5% (in adults) Using a standardized, validated assay, in the absence of factors that affect the accuracy of the A1C and not for suspected type 1 diabetes or 2hPG in a 75-g OGTT 11.1 mmol/L or Random PG 11.1 mmol/L Random= any time of the day, without regard to the interval since the last meal 2hPG = 2-hour plasma glucose; FPG = fasting plasma glucose; OGTT = oral glucose tolerance test; PG = plasma glucose Diagnosis of Diabetes 2013

11 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diagnosis of Prediabetes* TestResultPrediabetes Category Fasting Plasma Glucose (mmol/L) Impaired fasting glucose (IFG) 2-hr Plasma Glucose in a 75-g Oral Glucose Tolerance Test (mmol/L) 7.8 – 11.0Impaired glucose tolerance (IGT) Glycated Hemoglobin (A1C) (%) Prediabetes * Prediabetes = IFG, IGT or A1C % high risk of developing T2DM 2013

12 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Individualizing A1C Targets which must be balanced against the risk of hypoglycemia Consider % if: 2013

13 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetes in Canada: Prevalence by Province and Territory Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, NL 6.5% ON 6.0% QC 5.1% PE 5.6% NB 5.9% NS 6.1% MB 5.9% SK 5.4% AB 4.9% BC 5.4% NT 5.5% YT 5.4% NU 4.4% Age-standardized to the 1991 Canadian population. Age-standardized prevalence of diagnosed DM among individuals 1 year, 2008/09 NL, NS and ON had the highest prevalence, while NU, AB and QC had the lowest. < < < <

14 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, Prevalence of diagnosed diabetes among individuals aged 1 year, by age group and sex, 2008/09 Diabetes in Canada: Prevalence of Diagnosed Diabetes by age and sex Prevalence increased with age. The sharpest increase occurred after age 40 years. The highest prevalence was in the year age group. Prevalence (%) Canada Age group (years) Females Males Total Overall Prevalence 6.4% 7.2% 6.8%

15 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Patients with DM are more likely to be hospitalized for many conditions Public Health Agency of Canada (August 2011); using 2008/09 data from the Canadian Chronic Disease Surveillance System (Public Health Agency of Canada).

16 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Guideline Targets Achieved % of patients Leiter LA et al. Can J Diabetes 2013; in press

17 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Self-Monitoring of Blood Glucose (SMBG) What should we tell patients to do?

18 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Regular SMBG is Required for:

19 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Increased frequency of SMBG may be required: Daily SMBG is not usually required if patient:

20 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Pharmacotherapy in T2DM checklist CHOOSE initial therapy based on glycemia START with Metformin +/- others INDIVIDUALIZE your therapy choice based on characteristics of the patient and the agent REACH TARGET within 3-6 months of diagnosis 2013

21 Start metformin immediately Consider initial combination with another antihyperglycemic agent Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin A1C <8.5% Symptomatic hyperglycemia with metabolic decompensation A1C 8.5% Initiate insulin +/- metformin If not at glycemic target (2-3 mos) Start / Increase metformin If not at glycemic targets LIFESTYLELIFESTYLE Add an agent best suited to the individual: Patient Characteristics Degree of hyperglycemia Risk of hypoglycemia Overweight or obesity Comorbidities (renal, cardiac, hepatic) Preferences & access to treatment Other See next page… AT DIAGNOSIS OF TYPE 2 DIABETES Agent Characteristics BG lowering efficacy and durability Risk of inducing hypoglycemia Effect on weight Contraindications & side-effects Cost and coverage Other 2013

22 If not at glycemic target From prior page… Add another agent from a different class Add/Intensify insulin regimen Make timely adjustments to attain target A1C within 3-6 months 2013 LIFESTYLELIFESTYLE

23 Start metformin immediately Consider initial combination with another antihyperglycemic agent Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin A1C < 8.5% Symptomatic hyperglycemia with metabolic decompensation A1C 8.5% Initiate insulin +/- metformin If not at glycemic target (2-3 mos) Start / Increase metformin If not at glycemic targets LIFESTYLELIFESTYLE Add an agent best suited to the individual: Patient Characteristics Degree of hyperglycemia Risk of hypoglycemia Overweight or obesity Comorbidities (renal, cardiac, hepatic) Preferences & access to treatment Other See next page… AT DIAGNOSIS OF TYPE 2 DIABETES Agent Characteristics BG lowering efficacy and durability Risk of inducing hypoglycemia Effect on weight Contraindications & side-effects Cost and coverage Other 2013

24

25 Adapted from: Product Monographs as of March 1, 2013; CDA Guidelines 2008; and Yale JF. J Am Soc Nephrol 2005; 16:S7-S10. Antihyperglycemic agents and Renal Function Not recommended / contraindicated Safe Caution and/or dose reduction Repaglinide Metformin Saxagliptin Linagliptin Glyburide Thiazolidinediones 30 GFR (mL/min): < CKD Stage: Gliclazide/Glimepiride Liraglutide 50 Exenatide Acarbose 25 Sitagliptin mg mg 25 mg

26 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association What are the options for Insulin?

27 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Types of Insulin

28 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Types of Insulin (continued)

29 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Serum Insulin Level Time Analogue Bolus: Apidra, Humalog, NovoRapid Human Basal: Humulin-N, Novolin ge NPH Analogue Basal: Lantus, Levemir Human Bolus: Humulin-R, Novolin ge Toronto

30 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Time Serum Insulin Level Human Premixed : Humulin 30/70, Novolin ge 30/70 Analogue Premixed: Humalog Mix25, NovoMix 30

31 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association What about Hypoglycemia?

32 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 1.Development of neurogenic or neuroglycopenic symptoms 2.Low blood glucose (<4 mmol/L if on insulin or secretagogue) 3.Response to carbohydrate load Neurogenic (autonomic) Neuroglycopenic TremblingDifficulty Concentrating PalpitationsConfusion SweatingWeakness AnxietyDrowsiness HungerVision Changes NauseaDifficulty Speaking Dizziness Definition of Hypoglycemia

33 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Steps to Address Hypoglycemia 1.Recognize autonomic or neuroglycopenic symptoms 2.Confirm if possible (blood glucose <4.0 mmol/L) 3.Treat with fast sugar (simple carbohydrate) (15 g) to relieve symptoms 4.Retest in 15 minutes to ensure the BG >4.0 mmol/L and retreat (see above) if needed 5.Eat usual snack or meal due at that time of day or a snack with 15 g carbohydrate plus protein

34 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Macrovascular Disease Vascular Protection: Who and When?

35 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Vascular Protection Checklist 2013 A A1C – optimal glycemic control (usually 7%) B BP – optimal blood pressure control (<130/80) C Cholesterol – LDL 2.0 mmol/L if decided to treat D Drugs to protect the heart A – ACEi or ARB S – Statin A – ASA if indicated E Exercise – regular physical activity, healthy diet, achieve and maintain healthy body weight S Smoking cessation

36 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 40 yrs old or Macrovascular disease or Microvascular disease or DM >15 yrs duration and age >30 years or Warrants therapy based on the 2012 Canadian Cardiovascular Society lipid guidelines Among women with childbearing potential, statins should only be used in the presence of proper preconception counseling & reliable contraception. Stop statins prior to conception Who Should Receive Statins?

37 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Who Should Receive ACEi or ARB Therapy? 55 years of age or Macrovascular disease or Microvascular disease At doses that have shown vascular protection (ramipril 10 mg daily, perindopril 8 mg daily, telmisartan 80 mg daily) Among women with childbearing potential, ACEi or ARB should only be used in the presence of proper preconception counseling & reliable contraception. Stop ACEi or ARB either prior to conception or immediately upon detection of pregnancy 2013

38 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

39 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association JPAD = Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes POPADAD = Prevention of Progression of Arterial Disease and Diabetes PPP = Primary Prevention Project ETDRS = Early Treatment Diabetic Retinopathy Study PHS = Physicians Health Study WHS = Womens Health Study De Beradis G, et al. BMJ 2009; 339:b4531. ASA for 1 Prevention in Diabetes Meta analysis of 6 studies (n = 10,117) No overall benefit for: Major CV events MI Stroke CV mortality All-cause mortality Favors ASAFavors control/placebo JPAD POPADAD WHS PPP ETDRS Total 68/ /638 58/514 20/ / / / /638 62/513 22/ / / ( ) 0.97 ( ) 0.90 ( ) 0.90 ( ) 0.90 ( ) 0.90 ( ) Major CV events No. of events/No. in group ASAControl/placeboRR (95% CI) JPAD POPADAD WHS PPP ETDRS PHS Total 28/ /638 36/514 5/ / / / / /638 24/513 10/ / / / ( ) 1.10 ( ) 1.48 ( ) 0.49 ( ) 0.82 ( ) 0.40 ( ) 0.86 ( ) Myocardial infarction JPAD POPADAD WHS PPP ETDRS Total 12/ /638 15/514 9/519 92/ / / /638 31/513 10/512 78/ / ( ) 0.74 ( ) 0.46 ( ) 0.89 ( ) 1.17 ( ) 0.83 ( ) Stroke JPAD POPADAD PPP ETDRS Total 1/ /638 10/ / / / /638 8/ / / ( ) 1.23 ( ) 1.23 ( ) 0.87 ( ) 0.94 ( ) Death from CV causes JPAD POPADAD PPP ETDRS Total 34/ /638 25/ / / / /638 20/ / / ( ) 0.93 ( ) 1.23 ( ) 0.91 ( ) 0.93 ( ) All-cause mortality

40 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Summary of Pharmacotherapy for Hypertension in Patients with Diabetes Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg With Nephropathy, CVD or CV risk factors ACE Inhibitor or ARB Diabetes Without the above 1. ACE Inhibitor or ARB or 2. Thiazide diuretic or DHP-CCB Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria More than 3 drugs may be needed to reach target values If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired Combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target > 2-drug combinations

41 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Vascular Protection Checklist A A1C – optimal glycemic control (usually 7%) B BP – optimal blood pressure control (<130/80) C Cholesterol – LDL 2.0 mmol/L if decided to treat D Drugs to protect the heart A – ACEi or ARB S – Statin A – ASA if indicated E Exercise – regular physical activity, healthy diet, achieve and maintain healthy body weight S Smoking cessation 2013

42 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association What if we did all the right things? How much could we protect our patients?

43 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Gaede et al. NEJM. 2003: 348; STENO-2: Intensive Group Achieved Targets

44 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Intensive Group had Improved CV Outcomes P = Conventional therapy Intensive therapy Months of Follow-up RRR= relative risk reduction 53 % RRR Any CV event NNT = 5 Gaede et al. NEJM. 2003: 348;

45 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca STENO 2 Extended Follow-up: Effect of a multi- factorial vascular protective strategy on total mortality Total mortality (%) 3 Years of follow-up Conventional therapy Intensive therapy END OF TRIAL HR = 0.54 ( ) p = HR = 0.54 ( ) p = Gaede et al. N Engl J Med. 2008; 358(6):

46 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Gaede et al. NEJM. 2003: 348; STENO 2 – Microvascular Disease

47 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association What about Microvascular Disease? Nephropathy Retinopathy Neuropathy

48 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Chronic Kidney Disease (CKD) Checklist SCREEN regularly with random urine albumin creatinine ratio (ACR) and serum creatinine for estimated glomerular filtration rate (eGFR) DIAGNOSE with repeat confirmed ACR 2.0 mg/mmol and/or eGFR < 60 mL/min DELAY onset and/or progression with glycemic and blood pressure control and ACE inhibitor or angiotensin receptor blocker (ARB) PREVENT complications with sick day management counselling and referral when appropriate 2013

49 Counsel all Patients About Sick Day Medication List 2013

50 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Retinopathy Checklist SCREEN regularly DELAY onset and progression with glycemic and blood pressure control ± fibrate TREAT established disease with laser photocoagulation, intra-ocular injection of medications or vitreoretinal surgery 2013

51 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Delaying Retinopathy 1. Glycemic control: target A1C 7% 2. Blood pressure control: target BP <130/80 3. Lipid-lowering therapy: fibrates have been shown to decrease progression and may be considered 2013

52 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Neuropathy Checklist PREVENT with blood glucose control SCREEN with monofilament or tuning fork TREAT pain symptoms with anticonvulsants or antidepressants 2013

53 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 4.The following agents may be used alone or in combination for relief of painful peripheral neuropathy: – Anticonvulsants (pregabalin [Grade A, Level 1], gabapentin, valproate ) [Grade B, Level 2] – Antidepressants (amitriptyline, duloxetine, venlafaxine ) [Grade B, Level 2] – Opioid analgesics (tapentadol ER, oxycodone ER, tramadol) [Grade B, Level 2] – Topical nitrate spray [Grade B, Level 2] This drug is not currently approved by Health Canada for the management of neuropathic pain associated with diabetic peripheral neuropathy Recommendation 4

54 Why diagnose and treat GDM? Macrosomia Shoulder dystocia and nerve injury Neonatal hypoglycemia Preterm delivery Hyperbilirubinemia Caesarian section Offspring obesity (?) Offspring diabetes (?)

55 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Need a PRECONCEPTION checklist for women with pre-existing diabetes 1. Attain a preconception A1C of 7.0% (if safe) 2. Assess for and manage any complications 3. Switch to insulin if on oral agents 4. Folic Acid 5 mg/d: 3 mo pre-conception to 12 weeks post-conception 5. Discontinue potential embryopathic meds: Ace-inhibitors/ARB (prior to or upon detection of pregnancy) Statin therapy 2013

56 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 GDM diagnosis: Two approaches 2013

57 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 8.Women with pregestational diabetes may use aspart or lispro in pregnancy instead of regular insulin to improve glycemic control and reduce hypoglycemia [Grade C level 2 for aspart, Grade C, Level 3 for lispro]. 9.Detemir [Grade C, Level 2] or glargine [Grade C, Level 3 ] may be used in women with pregestational diabetes as an alternative to NPH. Recommendation 8-9: Management in Pregnancy for pre-gestational diabetes 2013

58 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association What about insulin analogues and oral agents among patients with GDM? May use rapid-acting analog insulin for postprandial glucose control – no difference in perinatal outcomes May use glyburide or metformin for women who are non-adherent to or who refuse insulin – Likely safe BUT it is OFF- Label no long-term data, need discussion with patient

59 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Neither evidence nor clinical judgment alone is sufficient. Evidence without judgment can be applied by a technician. Judgment without evidence can be applied by a friend. But the integration of evidence and judgment is what the healthcare provider does in order to dispense the best clinical care. (Hertzel Gerstein, 2012)

60 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CDA Clinical Practice Guidelines – for professionals BANTING ( ) – for patients

61 guidelines.diabetes.ca | BANTING ( ) | diabetes.ca


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